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Bone Case 6 Answers

1) Are there any abnormal areas of uptake?
2) If so, where?

There is a patchy abnormal uptake throughout the shaft of the left tibia with a further larger amount of abnormal uptake in the distal shaft of the left tibia involving surrounding soft tissues.

3) Is this likely to be a simple fracture?

No - the soft tissue uptake and abnormal tibial uptake warrants against this.
This is a biopsy-proven case of osteosarcoma with a large soft tissue component. A trivial fall during sporting activity produced a pathological fracture - it is a common story for the presenting complaint to be painful pathological fracture or persistent lump after trivial injury.
Additionally, there are further lesions along the proximal tibial shaft. Such "skip lesions" along the shaft of the tibia along with the clinical history render this (a) very likely to be an osteosarcoma (b) to be a poor prognosis (stage III) tumour.

4) Does the child need further imaging?

Yes. The role of bone scintigraphy is mainly to assess for other metastatic lesions. In particular, the lungs need imaging. The lungs are a classic site for osteosarcoma metastases. They may take up MDP (if the metastases are large). The lungs appeared normal on this study (images not shown), however, CT revealed 7 tiny lesions in various parts of the lung that were invisible on CXR, highly suspicious for haematogenous metastases.

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The text is entirely the opinion of the author and does not necessarily reflect that of RUH NHS Trust or the Bristol Radiology Training Scheme. Website content devised by Paul McCoubrie.